The Department of Veterans Affairs Office of Healthcare Inspections has uncovered lapses in the quality of care in three patients.

“In one case, inspectors substantiated a delay in the diagnosis of lung cancer in one patient, poor coordination of diabetes care in another and poor management of pain during and after a visit to the facility’s emergency room for a third patient.”
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The VA Office of Inspector General Office of Healthcare Inspections conducted a review to determine the validity of allegations that six patients received poor care at the Marion VA Medical Center (the facility). The complainants reported the allegations to Senator Richard Durbin. We did not substantiate lapses in quality of care for three patients. However, for the remaining three patients we substantiated a delay in diagnosis of lung cancer; poor coordination of diabetes care and insufficient procedures established for operation of the facility telephone call center; and poor management of pain during and after a visit to the facility emergency room (ER). We recommended that the facility Director: 1) obtain a peer review assessment of the care provided by radiologists interpreting chest x-rays for the patient with lung cancer; 2) monitor hospital discharges to ensure that patients have ongoing coordination of care; 3) establish telephone call center procedures in accordance with VHA policy; and 4) monitor ER pain management to ensure compliance with VHA policy. The VISN and facility Directors agreed with our findings and recommendations. The implementation plans are acceptable, and we will follow up on the planned actions until they are completed.